Dying Patients May Get Better Care When Generalists More Involved

Fewer ICU days, lower costs

Action Points

Note that this analysis of Medicare data suggested that greater primary care physician involvement at the end of life was associated with lower overall costs.

Be aware that areas with high primary care physician involvement had lower rates of hospice; a paradoxical result that has yet to be explained.

Greater involvement by primary care physicians in end-of-life care was associated with less intensive care and lower costs, researchers reported.

Chronically ill adults in areas with the greatest primary care involvement spent fewer days in hospitals, including hospital intensive care units (ICUs), during their last six months of life, Clair Ankuda, MD, of the University of Michigan Health System in Ann Arbor, and colleagues wrote in the journal Annals of Family Medicine.

Ankuda told MedPage Today that significant variation was seen in key end-of-life outcomes such as treatment by more than 10 physicians during the last six months of life and receiving ICU care during a final hospital stay, after adjusting for a wide range of potential confounders.

She noted that there has been an increase in the volume and intensity of end-of-life care in recent years that has not led to clear improvements in quality of care.

"Too many people in this country don't get the end-of-life care they tell us they want and their families tell us they want," Ankuda said. "This is a national problem, and we really haven't thought much as a country about the role of primary care physicians in coordinating this care."

Studies suggest that areas of the country with greater densities of primary care physicians have fewer ambulatory care-sensitive hospitalizations, lower mortality and less Medicare spending for the general Medicare population, Ankuda and colleagues noted.

"Given our aging population, understanding and optimizing the role of primary care physicians in care at the end of life is critical to both improve the care of the dying and reduce unnecessary, costly intensive care," they wrote.

The researchers analyzed Medicare Part B claims data from 2010 for 306 U.S. hospital referral regions (HRRs) in an effort to examine the impact of primary care physician involvement in end-of-life outcomes.

Ankuda and colleagues captured data on 1,107,702 Medicare Part B beneficiaries with chronic disease who died in 2010. Ratios of primary care to specialist visits during the last six months of life were determined for each HRR. These ranged from 0.38 to 2.55; overall the median ratio was 0.98 and the interquartile range was 0.77-1.21.

Regions with high versus low primary care physician involvement at the end of life had significantly different patient, population, and health system characteristics.

Adjusting for these differences, regions with the greatest primary care physician involvement had lower Medicare spending in the last two years of life ($65,160 versus $69,030; P= 0.003) and fewer intensive care unit days in the last six months of life (2.90 versus 4.29; P<0.001).

These regions also had lower end-of-life hospice enrollment (44.5% versus 50.4%; P=0.004), which the researchers characterized as a "paradox worthy of further investigation."

Ankuda noted that hospice services have proliferated in some regions of the country, such as the southern states, but their growth has been less robust in other regions. She said primary care physicians may be more prevalent in areas where their are fewer hospice services.

She added that studies also suggest that the longer a physician knows a patient the less accurate they are in predicting end of life, which could also be a factor in their failure to recommend hospice care.

The use of regional data was a significant study limitation that precluded assumptions about individual associations within regions, the researchers wrote.

"This study provides preliminary evidence that the involvement of primary care physicians is a source of regional variation in end-of-life care," they concluded. "In addition, it is promising that areas of high primary care physician involvement appear to have lower-intensity, lower-cost care."

Ankuda added that a significant obstacle to optimizing the role of primary care clinicians in coordinating end-of-life care is physician reimbursement.

"We are starting to see new payments in place to compensate physicians for this coordination of care work, but we are not there yet," she said. "I think it is really important to pay for the kind of care that matters to patients and families."

The study was funded by the Robert Graham Center Visiting Scholars Program.

The researchers declared no relevant relationships with industry related to this study.

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